The New England Journal of Medicine recently published an article by Matthew J. Press, MD, about the need for patients to have a quarterback to coordinate the team of care-givers. Dr. Press writes –

Care coordination is now a high priority in health care and is the backbone of new models of care, such as accountable care organizations, that aim to improve quality and reduce costs. But it remains an abstract concept to many people who are not on the front lines of clinical care, as well as to some on the front lines who lack (or don’t want to have) the quarterback’s view of the field. In replaying the highlights, we can learn some important lessons about care coordination.

He emphasizes the importance of personal relationships, both with the patient and with the other providers of care. “But,” he writes, “some changes in health care may be causing relationships to deteriorate. EMRs and the use of hospitalists probably have led to fewer personal interactions among physicians.”

Dr. Press was able to spend a great deal of time building relationships with his patient’s specialists because, “as a clinician-researcher, I had a patient panel about one tenth the size of the average primary care panel.”

He may not realize it (he doesn’t mention it), but he has just endorsed “concierge medicine.” Concierge physicians (they prefer the term “direct practice” these days) model their practices on having a smaller caseload, thereby knowing each patient very well and having the time to coordinate the work of all of the other professionals involved. And the number of concierge physicians is exploding under Obamacare.

Comments (12)

“Concierge” makes it sound somewhat exclusive, but there are many family doctors out there opening up direct care with very reasonable costs. This brings the patient-physician relationship back to the way it should be, without the interference of third parties.

I would suggest that instead of having a “patient care quarterback,” it would be much more efficient to have more physicians that practice in concierge medicine. Anything where physicians and the patients direct relationship is improved will improve quality outcomes.

We have long talked about how health policy wonks believe that doctors and hospitals should perform tasks for free that are not in providers’ self-interest. Who is going to pay the quarterback? In concierge medicine, the quarterback is paid by patient. Concierge medicine is often denigrated because lower-income people cannot afford to pay a retainer fee. Yet, lower-income people often have low health literacy, and most in need of a quarterback. That is why I find it interesting that Dr. Press is advocating for a health quarterback.

Another idea that comes to mind; doctor quarterbacks may not necessarily advocate for the preferences that patients actually want. Doctors have an immense toolkit full of treatments that are of only marginal benefits but are very expensive and often come with side effects. A good patient advocate needs to understand the patient and the patients’ needs go beyond being a science experiment.

You have a couple of good points, Devon. Many docs have no problem advocating for free, but if you add the numerous other non-productive things they have to do, there is really very little time for patient interaction/advocacy. Medicaid payment parity is now up for re-assessment but I’m not sure many docs ever recovered any of the increased payments. These are exactly the people that most need some health education and intervention. They are also often beset by factors that physicians have little or no control over, ie housing, transportation, family support.

Yes, we also need to be keenly aware that medical interventions come with both financial and physical costs and must be tailored specifically to each patient’s needs and abilities to handle them. This is why the practice of medicine is an
“art” as much as a science.

The irony is that coordination of care is least where its need is the greatest: in the ER where there is usually no connection to your PCP or your medical records unless you are in a closed panel HMO like Kaiser or you have a fluke congruency of your EMRs between your doc’s office and the ER. Maybe they are both EPIC.

And in hospital non-ambulatory care where your own doc is not welcomed by the hospitalists and sometimes cannot write to the chart legally. Coordination is often urgently needed when the case is complex. E.g. a case of sepsis in a diabetic with CHF on a patient with delirium.

Finally, if one is traveling and gets sick the chance that a doc in Spain can work with your own doc is very slim…unless some of your record is encrypted on the Net. This has to be the ultimate goal of coordination, I think.

Maybe, what we really need is a different practice model in health care. In medicine there is this old-fashioned idea that one busy professional is supposed to know everything about you and tell you what you need. The doctor is highly paid so you really cannot afford to pay him/her for the time needed to really manage your care. Medicine is so complex that no one person really can know it all anyway. In other areas of our lives, complex problems are managed using a systems approach. Yet, in health care we rely on one person who it too busy to really pay attention to us.

I appreciate the analogy, but I note that Americans are obsessed with quarterbacks. Most other team sports (other than cricket or baseball) do not have one person who starts with the ball. The captain is another member of the team, but he does all the jobs with everyone else. Think of soccer, ice hockey, basketball, etc.